Outcome of Unplanned Extubations in a Large Children’s Hospital

Abstract

Background:

Unplanned extubation (UE) is defined as a dislodgement of an endotracheal tube from the trachea that is not intentional. UEs may lead to physiological instability, cardiac arrest, and may require emergent tracheal intubation. UE is now recognized as an event of preventable harm by patient safety organizations. As part of our hospital-wide quality improvement work, the multidisciplinary committee performed a retrospective review of all UEs to determine contributing factors to UE and clinical outcomes to further develop quality improvement interventions to minimize UE events. The objective was to investigate the occurrence, contributing factors, and clinical outcomes of UEs in the neonatal intensive care unit (NICU), cardiac intensive care unit (CICU) and pediatric intensive care unit (PICU). We hypothesized that the occurrence, contributing factors, and outcomes of UEs were substantially different across three ICUs.

Methods:

A single-center retrospective review of all UEs in the neonatal, pediatric, and cardiac ICUs that were recorded in a prospective database used by the hospital-wide UE committee for the last 5 years. With IRB approval, data weas extracted through the Virtual Pediatric System or from the medical records by 3 respiratory therapists using REDCap for data collection and standardized operational definitions to ensure alignment of data extraction. Statistical analysis with Chi-square for the UE outcomes.

Results:

From 1/2016-12/2021, 399 UEs in 334 patients were reported; NICU 320 (80%), PICU 50 (13%), CICU 29 (7%). Patients with UE were small, with median weight of 5.4 kg (IQR 3.1-8.0). Patient demographics and breakdown of events by unit are presented in Table 1. Retaping of tracheal tube was identified in 13%. Most common adverse events with UE were hypoxemia (36%) and bradycardia (29%). Cardiac arrest occurred in 12%. Only 67% of UEs resulted in reintubation within 72 hours. The proportion of reintubation across the 3 units were significantly different: NICU 72%, PICU 64%, CICU 38%, P = .001.

Conclusions:

UEs occur commonly in a children’s hospital. Common contributing factors were identified as quality improvement intervention targets. While UE is associated with adverse events, reintubation rates within 72 hours were relatively low and variable across the units. This may imply early weaning and extubation from invasive mechanical ventilation should be considered whenever possible.